Matt Fish shares how PSMA PET imaging has helped guide treatment decisions throughout his journey with metastatic prostate cancer, including targeted radiation and hormone therapy. Joined by Dr. Alicia Morgans, he discusses how imaging can reveal changes in disease, influence treatment options, and help patients have informed conversations with their care teams.
Alicia Morgans:
Hi, my name is Alicia Morgans and I'm a gene medical oncologist at Dana-Farber Cancer Institute in Boston. I am so excited to be talking today with Matt Fish, who's joining me from New Hampshire. Matt, so happy to have you here.
Matt Fish:
I'm happy to be here. Thank you.
Alicia Morgans:
Wonderful. Matt, can you tell everyone a little bit about your story? You have prostate cancer.
Matt Fish:
I do.
Alicia Morgans:
Can you tell us a little bit about the state of that?
Matt Fish:
It's not just prostate cancer. Unfortunately, it's metastatic prostate cancer. I'll go over quickly how I got to this point.
Alicia Morgans:
Sure.
Matt Fish:
But it was discovered in 2020 after a biopsy, after my PSA numbers were rising and falling. And of course, given my age at 45, they just assumed it was inflammation, nothing crazy. They started checking at 35, and for 10 years they went up and down. So after a study started to rise instead of dropping, we knew something was up. And I then had the biopsy in 2020 and they determined that I had a Gleason score of higher than expected. So at that point, it made sense to have the radical prostatectomy done. Once I had that done, that surgery done in 2021, I of course then had to get scanned to determine where we were at at that point. Unfortunately, that scan showed that it did in fact spread to my hip and in that area, the hip as well as my pelvis.
And so back then, this was just five or six years ago, that scan was a lot worse than it is now. So that scan was 45 minutes in the tube. And at that point, what lit up in the scan was not guaranteed to show cancer. It could have been previous trauma. And now the scans are much more advanced, far better. The tube is bigger. The timeframe is 23 minutes, and now it only lights up what's actually cancer.
Alicia Morgans:
Let’s dig into this a little bit. One of the things that we wanted to talk about today were PSMA PET scans. And so when you talk about having a scan after your surgery, when the PSA was going up, was this a PSMA PET scan that you had back in 2021 or was this a bone scan? What kind of scan do you mean?
Matt Fish:
It was a PSMA, but not to the point where we're at now.
Alicia Morgans:
Okay.
Matt Fish:
And anytime a PSA rises, you're going to get a scan, of course. And I like what Prostate Cancer Foundation called scanxiety, you just don't know what's going to come up in that scan when you have rising numbers.
The last scan wasn't as good either. It shows that it's somewhat more throughout my body, but smaller lesions. So one of the first scans I got when the procedure got better, it had spread to my ribs and my back. That was able to be radiated because there was a larger concentration of the cancer there, and that was fine. But when it's more spread out and they're smaller lit up lesions in that scan, obviously makes it more difficult. So back on to a different type of therapy at that point, which would include, of course, ADT, abiraterone, procedures like that.
Alicia Morgans:
Okay. So when people are getting their follow-up for cancer, particularly for metastatic cancer, sometimes they'll get PET scans. Sometimes they don't, and that's completely appropriate. In your case, it sounds like it's been important to get PET scans over time to see what has generally been a relatively small number of spots.
Matt Fish:
Yes.
Alicia Morgans:
And let's talk a little bit about the point you made around if it's just one or two spots, sometimes we can use what we call metastasis directed therapy and radiate those spots and hope that we can have really a long period of time potentially where we've decreased the number of cancer cells in the body and maybe extended the time until we need to do some other treatment.
But it is important for people to know that once in a while, rather than one or two spots or even three to five spots, maybe we'll see more than that, seven, 10, 15, whatever the number may be. And when that happens, then we usually are not able to do that metastasis directed treatment that can be so helpful, and we often have to do things like switch the medicines that we're giving. Because medicines obviously are going to affect wherever the blood flows, all throughout the system rather than just on a pinpoint.
Matt Fish:
Correct. Correct. So I was very fortunate where after the scan showed, after I'd had the radiation, the scan showed no detection, I was able to just go on a relatively newer drug called NUBEQA. I was on that for a year. Everything was going great. PSA remained low, until it didn't. And then it shot up to an 11. The first thing that any oncologist is going to call for at that point is a scan. You have to do it. And that's when it showed that it had traveled a little bit more throughout lymph nodes, even a couple spots there.
However, it's been contained. I'm down into the low twos now thanks to some... I'm still on the NUBEQA in addition to hormone therapy and other areas of treatment that I'm on that are bringing it lower and lower and lower to the point where hopefully I can only be on NUBEQA again, which has very few side effects, if any.
Alicia Morgans:
Well, I am hopeful for that too. As we get to that point potentially, or as we just sort of think this through and for others who are facing PET scans, one of the things that you mentioned that I think we should dig into a little bit more is that there can be things lighting up. And that in all of our vernacular is really just saying that we see different colors, and the colors represent basically the intensity of the tracer or the dye that's injected in and how much uptake there is of that tracer. And the more cells that are there, the more uptake there will be of the tracer and the brighter the lighting up will be.
Matt Fish:
Yes.
Alicia Morgans:
Is this something that your doctor explained to you or talked to you about or showed you the pictures to try to help you understand that concept of lighting up on the scan?
Matt Fish:
Actually, yes. Dr. Pomerantz, who is an esteemed colleague of yours, I believe, is wonderful at that. We have a great patient-doctor relationship and he speaks to me in terms that I can understand it and it makes sense to me. And he doesn't hold back either, and I don't either. I want to make this journey as comfortable as possible for both myself, my family, anyone else involved, but especially with my oncologist. I don't want him to hold back and I want to be able to... We even negotiate. I'll say to him, "All right, I'm about to go get my PSA done. What do I need to be at to not go back on hormone shot?" And he'll say, "If you're under a two, fine."
And I just had this just happen last month, it was a 2.77. I had to do another month shot. So I can tell you that when I get below a two again, he's probably going to call for another scan, which is fine and we'll see where we're at at that point. But I can pretty much expect to do at least two scans, most likely, a year throughout this journey.
Alicia Morgans:
Okay.
Matt Fish:
And that's fine. I want to know where it's at. I want to know... The lesions that were on my hip and my pelvis, gone.
Alicia Morgans:
Great.
Matt Fish:
So the bone lesions are going away. It's the other lesions that are more lymph node and here and there that seem to just go off and do their own thing and are harder to treat, right?
Alicia Morgans:
Yeah.
Matt Fish:
Versus... You can't radiate that.
Alicia Morgans:
Well, I think also importantly, a PSMA PET scan shows us spots where the cancer may be sort of condensed or there may be a cluster of cells and it shows us that in the bones or in the lymph nodes or in an organ, if it happens to go there. Whereas our older scans, particularly bone scans, which were also nuclear medicine scans, these are scans that are done in that nuclear medicine department, those only showed us abnormalities in the bones.
So this type of scan shows us more detail. It shows us three dimensions where the bone scans were two. And it shows us things outside of the bones, which is also a really important thing because prostate cancer, like you've said, could be in lymph nodes, it can be in other places.
Matt Fish:
Yes.
Alicia Morgans:
So one of the other things you faced on your early scan was the potential that there might be things that were what we call false positives, so things that were not related to prostate cancer but looked abnormal. And there's also always the possibility that there could be a false negative. So we don't see anything on the scan, but there are cancer cells in the body. And we know that because the PSA is going up, telling us that they're there, they're perhaps just not in a cluster that's big enough for us to find on this scan.
Matt Fish:
Right.
Alicia Morgans:
So can you talk to us a little bit about false positives and false negatives, if you want to comment on those too, just so that people know that these are things that they have to be aware of and talk to their doctor about.
Matt Fish:
That's exactly right. Talk to your doctor. It can get very frustrating, false positive, false... I've been down that road, but that's why you got to... And have a qualified oncologist that you can speak candidly with. And I've gone through two, and don't be afraid to get second opinions. In fact, I have another doctor in Manchester and they'll try to make a recommendation. I say, "Not until I talk to Dr. Pomerantz. I'm not doing anything." So find the right oncologist, have that relationship with them and go over those things like false positive, false... Because it can get frustrating. You can only hope that it plays in your favor in a positive light. And if it doesn't, you figure it out together, you work together.
We're trailblazing. I mean, we're making so many inlet roads and everything that's going on with this disease. I'm confident that every year, and my oncologist tells me this, we're getting better and better at this and it's getting easier to treat. And I'm hoping that the side effects side of it continues to get better as well. Because it's all about quality of life, that really is what it's about.
Alicia Morgans:
Absolutely. And we all hope that for you too. I know that you're in incredible hands with Dr. Pomerantz.
Matt Fish:
Yeah.
Alicia Morgans:
So as we wrap up, what would your message be to other patients or their loved ones when they're thinking about, "Should I get a PSMA PET scan? Should I not? And how do I talk to my doctor about those results so that I get what I need out of that scan?"
Matt Fish:
Yeah. I mean, early detection is key. If you have a history of it in your family, if something doesn't feel right, if you're... There weren't many symptoms, if any, with me. So there was no reason to check me. I got diagnosed at 45, I had no family history. But if something doesn't seem right or you have a family history or... just talk to your doctor.
My advice is knowledge is power. That's why I'm here. I'm honored to be here, but this is an incredible event for me because I'm just going to continue to learn more and I'm going back to my oncologist, to Dr. Pomerantz, and I'm going to challenge him on some of the things I learned here. "Okay, where are we at with this? Can I look at this?" And just continue to do your own research as much, as you can being a regular Joe who's trying to understand this. I mean, I know more about prostate cancer now than I ever planned on in my entire life.
But do what you can and don't be afraid to ask the question. Don't be afraid to get a second opinion. Do everything you can. So my advice is please talk to your doctor. If you're 50 plus, especially if you have a family history, get it done. If they recommend the scan, go do it. Do not push back. Do it.
Alicia Morgans:
Yeah. So PSA testing, get the diagnosis. If in part of that evaluation, after a diagnosis for prostate cancer, someone says it's important to get a PSMA PET, get the PET.
Matt Fish:
Yeah.
Alicia Morgans:
And you may get one at diagnosis. You may get one if we're concerned that the cancer's come back. You may get one if we're trying to identify a place to radiate or even to use a liquid radiation type treatment that can be what we call a radioligand therapy. There are lots of instances where we might use a PSMA PET and when those come up, talk to your doctor. And I'm sure that people will appreciate hearing all of these insights from you today, so thank you.
Matt Fish:
Yeah. You're welcome. Thank you.
This interview was produced with the generous support of Novartis